Clinical Documentation Strategist

Lifespan; Providence (RI); On-site; USD 87,000 - 174,000; Full time

Job summary

Brown University Health seeks a Clinical Documentation Specialist to perform concurrent medical record auditing, ensuring documentation accurately reflects illness severity, mortality risk, and care complexity. The role requires collaboration with physicians, nursing staff, and coding teams to improve documentation quality.

You will develop concise queries, provide education, and maintain CDI data while targeting DRG accuracy and coding specificity.

Qualifications

• Licensed RN in Rhode Island with current license.
• BSN required; master's degree preferred.
• Physician Assistant or Nurse Practitioner with current RI license and 3 years clinical experience, or medical degree with 2 years clinical documentation experience.

Responsibilities

• Audit medical records concurrently to assess documentation for severity of illness, ROM, and risk adjustments.
• Collaborate with physicians, mid-level providers, nursing staff, and coding staff to improve documentation quality and specificity.
• Enter diagnoses and procedures accurately to support MS-DRG/DRG assignment and DRG reconciliation.
• Provide just-in-time education to clinicians and participate in formal education sessions.
• Maintain the CDI database and communicate discrepancies with coding staff.

Education

BSN (Bachelor of Science in Nursing)

Master's degree preferred

Tools

3M encoder

Job description

Brown University Health seeks a Clinical Documentation Specialist to perform concurrent medical record auditing, ensuring documentation accurately reflects illness severity, mortality risk, and care complexity. The role requires collaboration with physicians, nursing staff, and coding teams to improve documentation quality.

You will develop concise queries, provide education, and maintain CDI data while targeting DRG accuracy and coding specificity.